Awareness of Food Allergies and Allergens on the Menus of Restaurants and Cafes among Saudi Female University Students

Exposure to allergens could be life-threatening for people with food allergies. Restaurants and cafes are challenging environments for accommodating food allergies. This study aimed to measure King Saud University female students’ awareness about food allergens on restaurants’ and cafes’ menus. This cross-sectional study was conducted on 379 students aged 18 years and above. A paper-based questionnaire was used, which comprised 16 questions related to the definition of food allergies, food allergens, and food allergy symptoms; the definition and prevention of cross-contact of food allergies; emergency treatment procedures for food allergies; strategies for the prevention of food allergy reactions; customer expectations towards restaurants; and preventive measures taken for food allergies. The results indicate that the overall average score of food allergen awareness was 10.90, which falls in the higher range. Furthermore, female students in the age groups of 23 to 27 years and 33 to 37 years had higher levels of awareness than female students in the age group of 18 to 22 years. The results also showed that the level of awareness among science college and health college students was statistically significantly higher (p < 0.05) than that among humanities college students. Post-graduate students also showed a higher level of awareness of food allergens than bachelor’s students. These findings also indicate that listing all allergens in the restaurants and cafes’ menus statistically significantly (p < 0.05) increased the level of awareness of female students about food allergens on restaurants’ and cafes’ menus, compared to restaurants and cafes that do not list all allergens on their menus. In general, female students at King Saud University showed a high level of awareness about food allergies on restaurants’ and cafes’ menus. The study recommends assessing the impact of awareness of female students with and without food allergies on their practices and behaviors.


Introduction
Food allergies (FAs) are defined as an adverse reaction of the immune system when consuming food or food ingredients [1,2]. Although almost all foods can provoke an allergic reaction, milk, eggs, fish, shellfish, wheat, nuts, peanuts, and soybeans cause nearly 90% of reported reactions [3]. The skin prick test (SPT), intradermal test, and patch test are the various skin test methods (in vivo) used for the detection of IgE antibodies, but due to the simplicity, rapidity, and low cost, SPT is the most frequently used method [4]. Singleplex, multiparameter, or multiplex immunoassays are the various modern immunoassay methods used for the in vitro detection of serum-specific IgE to allergen molecules [5]. In the singleplex specific IgE immunoassays, only one analyte is measured per analysis. They determine serum-specific IgE using either liquid-phase allergens (i.e., chemiluminescence immunoassay) or solid-phase coupled allergens (i.e., fluorescence enzyme immunoassay) [5,6]. Light-initiated chemiluminescence assay (LICA) has been successfully used for the quantitation of food allergen-specific immunoglobulin E (sIgE)

Validation Process
Two types of validities, i.e., content and face validity, were determined for the questionnaire. For content validity, the first draft of the questionnaire consisting of 20 items was reviewed by a specialized committee of three faculty members in the field of nutrition. The committee members reviewed each item of the questionnaire individually and rated it based on clarity, simplicity, relevance, and obscurity. In response to the expert's comments and opinions, four items were removed, and some questions were restructured. After the content validity, a pilot electronic survey consisting of 16 items was sent to a randomized sample of 20 female students. The aim was to test the questions' clarity and how understandable they were, as well as to test the questionnaire's consistency, validity, and reliability. All participants reported that the elements were clear and understandable. In this study, the value of Cronbach's alpha coefficient using the Codder-Richardson method was 0.864, and at this level the internal consistency or reliability is considered as good, which shows that the response values for each participant across a set of questions are consistent. The validity coefficient using the Pearson Correlation coefficient was 0.92.

Statistical Data Analysis
Data were entered and analyzed statistically using the Statistical Package for Social Sciences (SPSS) version 22. Since the scores for the questionnaire were (1 or 0), the Kuder-Richardson 20 equation, a particular type of Cronbach's alpha coefficient suitable for use with the scores of test questions whose scores are (1 or 0) was used to calculate the reliability of the questionnaire. A Cronbach's alpha value of 0.7 is considered as minimally acceptable and 0.8 is considered as reliable. Moreover, the Pearson Correlation coefficient was used for calculating the validity of the questionnaire statements. In addition, to assess the awareness level, this study also identifies the differences between the levels of awareness based on different variables (college type; university stage; food allergy; the rate of visits to restaurants and cafes; age; listing all allergens on the menu in restaurants or cafes). The chi-square test was used to study the differences between the frequencies of the response to each question, and a t test was used for independent samples to study the differences that belong to two variables such as the university stage (bachelor's and postgraduate) and FA (students with or without a FA). One-way analysis of variance (oneway ANOVA) was used to study the differences in awareness related to age, college, rate of restaurant visits, listing allergens on the menus of restaurants, cafes frequented, and three-level variables and above; then, the Scheffe test was used to find the direction of the statistically significant differences. Statistical significance was set at p ≤ 0.05. Table 1 shows the demographic data of the research sample. Most (49.08%) of the participants were 18-22 years old, and only 3.43% were more than 38 years old. In addition, 84.17% were single, while 15.83% were married. Almost 38% of the participants had a family income between 5000 and 15,000 SR. Additionally, the table shows that approximately two-thirds (62.53%) of the participants were in the bachelor's degree program, while 37.47% of the participants were postgraduate students. Most (40.63%) were students at humanities colleges, and most of them (80.21%) did not have any FAs, while those with allergies represented 19.79%.

Frequency of Participants' Visits to Restaurants and Cafes and Their Food Allergy and Food Allergen Awareness
As seen in Figure 1, the frequency of female university students' visits to restaurants and cafes was quite low. The obtained data show that 72.82% of participants visited restaurants and cafes only once or twice per week, 24.80% visited three to four times per week, while only 2.37% visited restaurants and cafes five to seven times a week. Figure 2 depicts the opinion of students on the listing of all allergens on the menu in restaurants and cafes. It was observed that 48.55% of participants considered that food allergens are never listed on the menus at restaurants and cafes, while 48.28% considered that food allergens are sometimes listed on menus. On the other hand, 3.17% of the sample reported that all food allergens are always listed on menus.

Frequency of Participants' Visits to Restaurants and Cafes and Their Food Allergy and Food Allergen Awareness
As seen in Figure 1, the frequency of female university students' visits to restaurants and cafes was quite low. The obtained data show that 72.82% of participants visited restaurants and cafes only once or twice per week, 24.80% visited three to four times per week, while only 2.37% visited restaurants and cafes five to seven times a week. Figure 2 depicts the opinion of students on the listing of all allergens on the menu in restaurants and cafes. It was observed that 48.55% of participants considered that food allergens are never listed on the menus at restaurants and cafes, while 48.28% considered that food allergens are sometimes listed on menus. On the other hand, 3.17% of the sample reported that all food allergens are always listed on menus.

Frequency of Participants' Visits to Restaurants and Cafes and Their Food Allergy and Food Allergen Awareness
As seen in Figure 1, the frequency of female university students' visits to restaurants and cafes was quite low. The obtained data show that 72.82% of participants visited restaurants and cafes only once or twice per week, 24.80% visited three to four times per week, while only 2.37% visited restaurants and cafes five to seven times a week. Figure 2 depicts the opinion of students on the listing of all allergens on the menu in restaurants and cafes. It was observed that 48.55% of participants considered that food allergens are never listed on the menus at restaurants and cafes, while 48.28% considered that food allergens are sometimes listed on menus. On the other hand, 3.17% of the sample reported that all food allergens are always listed on menus.    Table 2 depicts the food allergy and food allergen awareness of participants in relation to restaurant and cafe menus. It was noted that 87.6% of participants were aware that food allergy reactions occur immediately or within a few hours after the food is consumed, and almost 74% responded correctly that the respiratory system, gastrointestinal tract, and skin are all affected by food allergy reactions. Most of the participants were aware of the top food allergens and best possible treatment for controlling a severe allergic reaction. Almost 61% correctly responded that potato is not among the top food allergens, 51.19% correctly identified the risky food items for a person who has a FA, and 67.5% were aware that epinephrine is the best possible treatment for controlling a severe allergic reaction. Almost 60% of participants were aware of the correct definition of allergen cross-contact, and 81.5% believed that avoiding the food that causes the allergic reaction is the best possible way to prevent a reaction. Seventy-seven percent of participants felt that all restaurants and cafes should provide allergen-free menu options, mark the eight major food allergens on the menus, and list all the ingredients of food and drinks. The study also showed that 85.75% of participants believe that each restaurant and cafe should have procedures in place that allow food allergy sufferers to more easily choose from the menu in order to avoid allergens that may cause an allergic reaction. Table 2. Food allergy and food allergen awareness of participants in relation to restaurant and cafe menus (n = 379).

Awareness Questions N (%)
1. What is the average time it takes for a food allergy reaction to occur after the food has been consumed? (a) Immediately or within a few hours after the food is consumed * 332 (87.6) (b) 24 h after the food is consumed 40

Awareness Questions N (%)
9. Which of the following is the correct definition of allergen cross-contact? (a) Contact between raw and cooked foods 27 (7.12) (b) Contact between allergen-containing foods and non-allergen-containing foods* 226 (59.63) (c) Contact between allergen-containing foods and raw meat 17 (4.49) (d) Contact between allergen-containing foods and dairy products 109 (28.76) 10. Which of the following practices could cause cross-contact? (a) Using the same utensil for preparing allergen-containing food and allergen-free food 152 (40.1) (b) Not washing hands but using a fresh pair of gloves before handling the allergen-free food 4 (1.06) (c) Preparing allergen-free food on a countertop that has not been thoroughly cleaned and sanitized 17 Table 3 shows a statistically significant difference in favor of correct answers at the 0.01 level between the frequency of correct answers and the frequency of incorrect answers in question numbers 1, 2, 4, 6, 7, 8, 9, 12, 14, 15, and 16. This signifies that the number of correct responses to the above-mentioned questions was statistically more significant than the number of incorrect answers. This outcome indicates that the research samples from the female campus of King Saud University possess high awareness of food allergens in the restaurant and cafe menus included in these 11 questions. For both questions 3 (The body reacts negatively to which of the following foods to cause FAs?) and 11 (Why can fried foods be dangerous for people with FA?), a statistically significant difference at the 0.01 level between the frequency of correct answers and the frequency of incorrect answers in favor of the number of incorrect answers was observed. This means that the number of incorrect answers to these two questions was higher and statistically more significant than the number of correct answers. This suggests that the research samples had low awareness of food allergens on the menus of restaurants and cafes. There were statistically insignificant differences at the 0.01 level between the frequency of correct answers and the frequency of incorrect answers to questions 5, 10, and 13, indicating that the research sample was moderately aware of food allergens on the menus of restaurants and cafes. At the 0.01 level, there was a statistically significant difference in the frequencies of students' awareness about food allergens on restaurant and cafe menus (high, moderate, low) in favor of students with a high level of awareness. This suggests that the number of students with a high level of awareness was significantly higher than the number of students with moderate and low levels of awareness. The results depicts that the overall average awareness was 10.90, which falls within the high range (>10.66 to 16-high). Table 3. Study on the frequencies of differences between the response to each question and the participants' awareness of food allergies and allergens on the menus of restaurants and cafes.

Question
No.  Table 4 shows the differences in food allergy awareness due to the age variable. A statistically significant difference (p ≤ 0.01) in food allergy awareness in relation to restaurant and cafe menus was noticed due to this variable. According to the Scheffe test results, KSU female students aged between 23 and 27 years old were more aware of food allergens on restaurant and cafe menus than female students aged between 18 and 22 years old, and this difference was statistically significant at the 0.05 level.  Table 5 shows the differences in food allergy awareness due to the college variable. Statistically significant differences (p ≤ 0.01) were noticed in relation to awareness about Healthcare 2023, 11, 1259 9 of 15 food allergens on restaurant and cafe menus due to this variable. Based on the Scheffe test findings, it is clear that the science college and health college students were more aware of food allergens on restaurant and cafe menus than students at humanities colleges, and this difference was statistically significant at the 0.05 level. However, a statistically insignificant difference (p > 0.01) was observed in the awareness of students regarding food allergens on restaurant and cafe menus among students from the health and science colleges.  Table 6 shows a statistically significant difference (p ≤ 0.05) between the mean scores of the bachelor's and postgraduate female students in relation to awareness about food allergens on restaurant and cafe menus, with the mean score of the postgraduate students being higher, i.e., female postgraduate students' awareness about food allergens on restaurant and cafe menus was statistically significantly higher than that of female bachelor's students.  Table 7 shows statistically insignificant (p > 0.05) differences in the awareness among students about food allergens on restaurant and cafe menus due to the restaurant/cafe visit frequency (high, medium, and low) variable. Table 7. Study on the differences in awareness of food allergies and allergens on the menus of restaurants and cafes according to the frequency of visits to restaurants and cafes.  Table 8 shows a statistically insignificant difference (p > 0.05) between the mean scores of students with and without a FA in the level of awareness about food allergens on restaurant and cafe menus, indicating the similarity in the level of awareness about food allergens on restaurant and cafe menus in female students both with and without a FA.  Table 9 shows a statistically significant difference in awareness of food allergens on restaurant and cafe menus (p ≤ 0.01) due to the variable of listing all allergens on the menu. Based on the Scheffe test results, it is evident that visiting restaurants and cafes that sometimes list all allergens on the menu increases the statistically significant (at the 0.05 level) outcome of female students' awareness of food allergens compared to visiting restaurants and cafes that never list all allergens on the menus. Table 9. Study on the differences in the awareness of food allergies and allergens in the menus of restaurants and cafes according to the variable of listing all food allergens on the menu.

Discussion
FA prevalence is an increasingly important public health issue. Nowadays, especially among youth, dining outside the home at restaurants and cafes is a popular pastime, and dependency on and craving of convenience foods and fast foods have rapidly increased [19]. Even though the event of dining out provides an opportunity for social bonding, relaxation, and convenience, it may cause health problems for individuals with food allergies [20]. A survey conducted in 2020 across eight European countries on the effects of having a peanut allergy reported that around 89% of subjects felt restricted by the allergy; in terms of dining out and selecting a destination, 65% felt isolated while 90% felt tense about the whole procedure [21]. For a variety of reasons, such as the improper handling of food allergens, inadequate employee awareness of food allergies, hidden allergens, and miscommunication between employees and customers, food allergy reactions have commonly occurred in restaurants or commercial food service establishments [17]. Therefore, an awareness of food allergies is crucial to prevent accidents. Bearing this in mind, the present study assessed people's awareness of food allergies and allergens on the menus of restaurants and cafes among female university students.
Similar to this study, a previous study assessing food service employees' food allergy knowledge, attitudes, practices, training, and training needs reported that the majority of the respondents were 18-25 years old [16]. In this study, almost 20% of the participants were allergic to at least one food, which is in accordance with a previous study [22], which reported that almost 15% of participants were allergic to at least one food, but that their allergy did not affect their life significantly. Another study indicated that responders were well aware of cow's milk allergies [23]. The current findings are also congruent with the findings of Choi et al. in 2012 [16], whose study targeted students and employees at on-campus residential restaurants and cafes and found that respondents were aware and highly knowledgeable about food allergy definitions and how to deal with clients who have food allergies; however, most of the responders were not able to identify the common food allergens from the list provided to them and were not aware of the best treatment available for controlling a severe food allergy reaction. Barnett et al. (2011) reported that food prepared exclusively with safe ingredients can still cause reactions if prepared using utensils that were in contact with allergens [11]. Awareness of allergens is of great significance, because a lack of awareness may cause cross-contact with an ingredient without the realization that the ingredient is a major allergen, which can in turn cause serious harm to people with allergies [24].
In this study, the overall awareness was 10.90, which falls within the high range. This indicates that the research sample possesses a high level of awareness regarding the food allergens on restaurant and cafe menus. The reason for the high level of awareness among the research sample could be that the participants were educated. Various studies in different countries have reported different levels of food allergy knowledge. Studies in Iran [25] and Germany [13] have reported suboptimal levels of food allergy awareness among the study samples, while in contrast, some studies in Turkey [14,26] reported a moderate level of food allergy awareness. In a study examining differences in parent knowledge about pediatric food allergies [27], suboptimal FA knowledge among parents was reported. This may be due to the fact that parents can forget the information supplied by doctors, which leads to a lack of information application. Therefore, doctors and parents of patients should use methods that help them to understand and maintain instructions, such as an educational pamphlets and recording the information [28,29]. Social media is another source of information that can influence awareness. The findings of a previous study indicated that apart from other people's food allergy experiences and advice, social media allows people to access up-to-date information regarding food allergies [30].
A previous study [22] showed that young people aged 15 to 20 had a high level of awareness of the basics of food allergies, while another study on adolescents reported that adolescents aged 13 to 20 had only basic knowledge of allergies [31]. The results of our study showed that awareness about food allergies and allergens on restaurant and cafe menus among KSA female students aged 33 to 37 was higher than that of female students aged 18 to 22. This outcome suggests that the older the students are, the higher their level of awareness about food allergens on restaurant and cafe menus. A study of pediatricians found that their knowledge levels were significantly related to their age, with older pediatricians having higher knowledge of food allergies [32]. In contrast, another study revealed an insignificant difference in food allergy knowledge based on age [33].
The difference in understanding between health/science colleges and humanities colleges might be attributed to the universities' teaching curriculum. This could also be due to the training provided to students at health and science colleges, where theoretical information is applied practically, thereby increasing their experience and knowledge. In a previous study on fifth-semester medical students, it was found that these students possess a good level of knowledge of food allergic reactions (up to 85.2%); indeed, medical students represent a good way to convey information about food allergic reactions because they are future doctors [34]. In the same vein, another study found that science students had significantly higher levels of nutritional knowledge than humanities and social sciences students, because science students are more likely to be exposed to nutritional information in their studies than humanities and social sciences students [35]. In contrast, a study on physical education students [36] found that the participants had insufficient knowledge of nutrition, probably due to a lack of application of the information gained through study and the low usage of this information in behavioral practices and daily habits.
Female postgraduate students' level of awareness about food allergies and allergens on restaurant and cafe menus was significantly higher than that of female bachelor's students. This might be because the higher the educational degree, the greater the individual's level of awareness, which is consistent with the findings of a study that found that participants with a fellowship and a bachelor's degree had a higher awareness of food allergies than their counterparts [14]. Another study found that education level had a significant impact on food allergy knowledge; these findings might indicate that higher education levels are related with better skills, providing respondents with more efficient methods to fully understand food allergy information [33]. In addition, a previous study was conducted to assess trans-fat knowledge among a group of health-interested adults to make recom-mendations regarding dietary education needs; the findings showed that level of education was associated with the degree of trans-fat knowledge.
Those participants with bachelor's, master's, and PhD degrees outperformed those with education levels lower than a bachelor's degree [37]. This outcome is in line with the findings of a study conducted in Iraq, which mentioned that the level of awareness was related to the level of education [38]. Our results are also consistent with another study that examined dietitians' knowledge of the biological roles of inorganic food nitrates in the United Kingdom and explored potential differences based on participants' educational levels. Individuals with different levels of education had significantly varying levels of knowledge about inorganic nitrates, with those having master's or PhD degrees having greater levels of knowledge than those with bachelor's degrees [39].
In this study, statistically insignificant differences in the awareness about food allergens on restaurant and cafe menus among students due to the variable of restaurant/cafe visit frequency (high, medium, and low) were observed. One reason for this might be that the research sample consisted of participants from the same university, which increased the possibility that they often visit the same restaurants in the same city. Another reason might be that the food providers and employees have sufficient awareness, which is reflected in the awareness of female students who visit those restaurants and cafes. To the best of our knowledge, no study has addressed the effect of the frequency of weekly visits to restaurants and cafes on food allergen awareness; thus, we consider it necessary to conduct further research on this variable. In this study, no difference in the awareness among participants with or with or without food allergies about food allergens on restaurant and cafe menus was noted. It is possible that this outcome was due to enhanced levels of attention and consciousness among people with food allergies as a result of their anxiety about food allergy complications. People without food allergies may have a high level of awareness due to their relatives or friends who have food allergies. In contrast, a previous study found a difference in awareness levels among those with and without food allergies, showing that people with food allergies were more aware than those without food allergies [22].
The high levels of awareness about food allergens is due to the Saudi Food and Drug Authority (SFDA) enforcement of legislation requiring restaurants and cafes to provide information on allergens on menus. Furthermore, our findings are in agreement with those of another study [40], which found that 58.9% of the participants reported observing allergen information on menus after the SFDA enforced the legislation. Despite the EU-wide legislation introduced in December 2014 requiring restaurant servers to provide written and verbal information about one or more of the fourteen most common food allergens in their food, some studies have found that food allergens are not listed on menus or on other documents, such as on restaurant signs [41]. These findings are concerning, because food-allergic customers often rely on written information about food allergens while dining out to help them avoid potential allergen exposure [42,43]. Therefore, enhanced efforts by restaurant and food service employees are needed to build confidence in foodallergic customers and to provide accurate and reliable information about the risks of food allergens [44].

Conclusions
The current study investigated the awareness of food allergies and allergens in the menus of restaurants and cafes among Saudi female university students. Overall, the participants were knowledgeable about food allergies and allergens on restaurant and cafe menus. It was observed that various factors such as age, education, and type of college attended have been associated with higher awareness in students. The outcomes of this study further show that most of the participants were cognizant of the preventive measures needed to ensure their own safety. Although the SFDA has enforced legislation specifying that restaurants and cafes should provide information on allergens on menus, most of the students have reported that restaurants' or cafes' menus either do not mention or provide only a small amount of information about allergens; we therefore wish to motivate restaurants and cafes to provide more information about allergens on their menus.
Students can play an active role in improving consumer safety and health. University students can encourage and educate other students, and they can also increase the awareness of community workers and the public by providing training on food allergies and their management.
The major limitation of this study was that this study comprised only university students that were from one university, which might be responsible for the overrepresentation of awareness; thus, the results from the survey cannot be generalized beyond our participants. Only 19.79% of participants in this study had an FA, so the results may not cover the entire spectrum of opinions in relation to people with food allergies.

Institutional Review Board Statement: The Ethical Committee for Human and Social Research at
King Saud University approved this study (KSU-HE-20-700). Written consent to participate in the study was obtained from each participant.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The data presented in this study are available on request from the corresponding author.